Right on the Money

Guest Post from Deborah L. Benzil, MD, FACS, FAANS
Member, AANS Board of Directors
Chair, AANS/CNS Communications and Public Relations Committee
MKMG
Columbia University Medical Center
Mt Kisco, New York

debThere is not much about healthcare policy on which everyone agrees; however one irrefutable fact acknowledged by most is that U.S. healthcare costs are rising, outstripping inflation, and thus exerting pressure on many aspects of the economy. In 2012, healthcare costs topped $2.8 trillion – and this trend shows no end in sight! Not only do these costs act as a drag on our economy, but Americans feel the pain directly, since over the last decade insurance premiums for the average family of four have risen more than 100 percent.

Beyond this basic fact, however, a fierce debate rages. Much of the recent focus on containing healthcare costs seems directed primarily at physicians. The debacle for holding down physician expenditures, known as the Medicare “sustainable growth rate,” is just one component of this process. (Little mentioned, and entirely forgotten, is the fact that the SGR was the only cost containment process left in place from the Balanced Budget Act of 1997, while others that impacted other healthcare providers, including hospitals and nursing homes, were lobbied away). Physician services represent roughly 20 percent of each healthcare dollar, compared with more than 30 percent for hospital costs. Of the 20 percent for physicians, only a portion becomes actual physician take-home pay, as most of this goes towards practice overhead, which is high (and rising).

National Health Expenditures 2014 (projected) (2)

Elizabeth Rosenthal, in her excellent and insightful news analysis, “Medicine’s Top Earners Are Not the M.D.’s” discusses another closely held secret within our current healthcare system: the exorbitantly high administrative costs (in hospitals, health insurance, and healthcare systems) presently being paid. The article notes that Mark T. Bertolini, thecroppedRosenthal_400x400 chief executive of Aetna, earned a salary just under $1 million, but his total annual compensation was in excess of $35 million! Based on data from the Medical Group Management Association, he earned more than 160 primary care physicians and 90 specialists combined! And he is just one executive of one insurance carrier.

So returning to what we all agree on — healthcare costs are rising too quickly. However, curtailing those costs should not break the back of those (the physicians) that provide the critical diagnostic and therapeutic interventions that help patients. Neurosurgeons provide accessible, compassionate care for patients with some of the most devastating medical conditions. We are there for our patients. We will work with those voices of reason to help ensure value in healthcare delivery and appropriate costs. But let us be RIGHT ON THE MONEY by understanding:

  1. Physicians were the only sector of healthcare whose costs were essentially capped by the Balanced Budget Act of 1997.
  2. Physician services represent a small fraction (less than 20 percent) of all healthcare dollars, the slowest growing component of healthcare costs.
  3. Administrators salaries are today’s TOP EARNERS in medicine, while providing no direct healthcare services and little or no direct benefits to patients.
Posted in Access to Care, Guest Post, Health, Healthcare Costs | Tagged , , |

Neurosurgery Meets with Congress during Alliance of Specialty Medicine’s Legislative Conference

Guest Post from Alliance of Specialty Medicine spokesperson, Alex B. Valadka, MD
Chief Executive Officer, Seton Brain and Spine Institute
Austin, Texas

Alex and Rep  Roger Williams

Dr. Valadka (left) visiting Rep. Roger Williams (R-Texas).

This week, I attended the Alliance of Specialty Medicine’s annual Capitol Hill Advocacy Conference. More than 100 participants from 13 medical societies – including the AANS and CNS – attended the three-day event in Washington, D.C. The agenda included lengthy discussions with influential members of Congress who shared their perspectives on critical healthcare issues. We also heard presentations from, and exchanged ideas with, leaders from the Centers for Medicare and Medicaid Services (CMS) and National Committee on Quality Assurance (NCQA).

Alex ocare

While visiting Rep. Bill Cassidy, MD (R-La.), Dr. Valadka stands next to the Obamacare “Tower of Regulations.

Congressional speakers included: Senator Tom Coburn (R-OK); and Representatives Ami Bera, MD (D-CA); Michelle Lujan Grisham (D-NM); Raul Ruiz, MD (D-CA); and Fred Upton (R-MI), chairman of the House Energy and Commerce Committee. Patrick Conway, MD, Deputy Administrator for Innovation and Quality & Chief Medical Office for CMS and Will Robinson, Manager of Public Policy for the NCQA provide insight on physician network adequacy and quality-related programs required by Medicare and the Affordable Care Act. We also gained valuable insights about the upcoming November elections from Nathan Klein with the National Republican Senatorial Committee and Anne Caprata with the Democratic Senatorial Campaign Committee.

Most importantly, conference participants went to Capitol Hill to meet with members of Congress to discuss important healthcare issues. The advocacy topics we broached included repealing the Independent Payment Advisory Board (IPAB), graduate medical education funding, medical liability reform, and fair Medicare physician payment by repealing the flawed sustainable growth rate (SGR) formula and allowing patients and physicians to privately contract without penalty.

Neurosurgeons joining me at the conference were Drs. Maya Babu, Rick Boop, Bob Harbaugh, Brain Ragel, Dan Resnick, Clemens Schirmer, Konstantin Slavin, Mark Spatola, and John Wilson. Together, we met with dozens of congressional offices on behalf of organized neurosurgery and the Alliance.

With rising healthcare costs, an increasing senior population, the physician workforce in jeopardy and issues of quality, privacy and access on the line, the stakes for specialty physicians and their patients are high. Thankfully, the Alliance gives all of specialty medicine a voice, which is being carried through the halls of Congress.

group photo hill w Mark

Members of the Alliance on Capitol Hill

Posted in Access to Care, Congress, GME, Guest Post, Health, Health Reform, Healthcare Costs, IPAB, Medical Innovation, Medical Liability, Medicare, Quality Improvement, SGR, Workforce Shortage | Tagged , , , , , , , , , , , , , |

Independence Day: New Freedom for those with Back Pain

Guest Post by Daniel K. Resnick, MD
President, Congress of Neurological Surgeons
Professor, Vice Chairman and Program Director
Department of Neurosurgery University of Wisconsin
Madison, WI

resnickLast week, while most people were getting ready to celebrate the July 4th holiday, there were two critical developments in the arena of back pain and spine disorders. First, the July 2014 Journal of Neurosurgery: Spine published updated guidelines on lumbar spine fusion procedures. Second, an important study on the use of steroid injections for spinal stenosis was published in the New England Journal of Medicine.

First, let’s address the importance of the guidelines published. To produce meaningful guidelines, experts in organized neurosurgery and orthopedic surgery banded together to evaluate the recent literature on lumbar spine fusion procedures and to publish up-to-date evidence-based recommendations on their use. These guidelines wereSpine Guidelines Artwork sponsored and published by the American Association of Neurological Surgeons/Congress of Neurological Surgeons Joint Section on Disorders of the Spine and Peripheral Nerves. Given the many recent advances in the arena of spinal fusion, it was crucial to update the initial version of these guidelines published in the same journal in 2005. The guidelines demonstrate that spinal fusion procedures constitute an established and successful therapy for patients with pain and/or neurological deficits due to degenerative diseases of the lumbar spine. Some of the notable findings were:

  • The current evidence does not identify a single best treatment alternative for patients with intractable low-back pain. For patients whose pain is resistant to conservative therapy, however, lumbar fusion may be recommended.
  • For patients suffering from a lumbar herniated disc, the surgical option of choice remains a lumbar discectomy. Some evidence suggests that lumbar fusion may be considered an option when a herniation is associated with spinal instability, chronic low-back pain and/or severe degenerative changes.
  • The medical literature does not support the use of lumbar epidural injections for long-term relief of chronic back pain without radiculopathy.
  • The use of back braces is not recommended for preventing low-back pain in a general working population. However, in laborers with a history of back pain, bracing does reduce lost workdays.

The epidural steroid injection article, published in the New England Journal of Medicine, delivers strong evidence for appropriate care of back pain and spinal disorders. Often, patients have sought steroid injections as an alternative to surgery, an intervention believed to improve quality of life with limited risks. The recent paper was a randomized, blinded, controlled study that demonstrated that the addition of steroids did not significantly improve three or six week outcomes compared to the injection of anesthetic alone. These recommendations for injections to provide relief of symptoms of lumbar stenosis have always been problematic, as lumbar stenosis is a long term issue and the value of a few days or weeks of relief may be questioned when one considers the costs and potential complications of these procedures. Insurance company requirements for injections prior to surgery will also need to be revisited, as the only interventions shown to have long-term efficacy for neurogenic claudication are surgical.

Several other interesting points are raised by the new study, including:

  • There are systemic effects of steroid injection that need to be considered in a risk benefit ratio when the added benefit of steroids appears to be minimal if any.
  • The important role that the placebo effect plays in the management of pain.

Further research is definitely required and should be stratified by detailed anatomical and clinical descriptions of the pain syndrome being treated.

At the end of the day, it’s important for patients to have access to therapies for treating back pain and spine disorders. Neurosurgeons are committed to identifying the right treatment, for the right patient, at the right time to optimize outcomes, and reduce healthcare costs.

For additional information, see the Spine Patient Outcomes Research Trial (SPORT) study and the North American Spine Society’s guidelines for the Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis.

Posted in Access to Care, Guest Post, Guidelines, Health, Spine Care |